造影剂肾病指在血管造影或其他医学操作(如尿路造影术)中使用碘化造影剂后出现的急性肾损伤.造影剂肾病发病机制复杂,临床无特效治疗方式,所以需要找到特效预防治疗措施刻不容缓.本文就造影剂肾病发病机制、危险因素、防治措施作一综述.

患者,男,66岁,因"发现血肌酐升高半年余."于2019-04-13入院.患者半年余前无明显诱因下出现咳嗽、气急至外院呼吸科就诊时发现血肌酐升高,当时血肌酐170.2μmol/L,白蛋白26.3g/L,球蛋白55.7g/L,血红蛋白95g/L,免疫球蛋白G 42.3g/L,尿检结果未见,查肺部CT:两肺间质性肺炎考虑,考虑:特发性肺间质纤维化,予"吡非尼酮400mg每日两次"治疗,气急有好转.2月前患者咳嗽加重,至我院呼吸科就诊,查血肌酐408μmol/L,无明显尿量减少,未服用中草药、止痛药等,遂至我科就诊,门诊拟"肾功能不全"收住入院.既往有糖尿病1年余,予诺和锐30R 14单位每日一次治疗,血糖控制一般.

溶血尿毒综合征(hemolytic uremic syndrome,HUS)是多种病因引起的血管内溶血的微血管病,以微血管内血栓形成伴相应器官受累为表现的一组临床综合征,是血栓性微血管病的一种.该病以微血管内溶血性贫血,血小板减少和急性肾功能衰竭作为临床三大特征[1].现报道我院1例流产后非典型溶血尿毒综合征患者的诊治经过,并进行相关文献复习,使临床医师加深对该疾病的认识和了解,以免漏诊及误诊.

目的了解血液透析（HD）和腹膜透析（PD）患者蛋白质能量消耗（PEW）状况,探讨不同透析人群中PEW的相关危险因素。方法纳入2018年12月至2019年6月在浙江大学医学院附属第一医院规律HD患者357例和腹膜透析中心管理的PD患者324例为研究对象,根据国际肾脏营养和代谢学会（ISRNM）的诊断标准调查HD和PD患者PEW发生率,用生物电阻抗法（BIA）、生化检查、人体学测量等方法评估透析患者的营养状况,并进一步分析不同透析人群PEW的危险因素。结果与非PEW患者相比,诊断PEW透析患者人体成分分析指标水分比率（ECW/TBW）、体细胞质量（BCM）、骨骼肌（SMM）差异有统计学意义（P＜0.001）。HD患者PEW发生率明显低于PD患者,两组差异有统计学意义（P＜0.001）。对HD患者进行二元Logistic回归分析显示,炎症状态[C反应蛋白（CRP）≥8 mg/L,OR=2.695,95%CI 1.429～5.026]是预测PEW发生的危险因素,而Kt/v（OR=0.182,95%CI 0.062～0.508）是预测HD患者发生PEW的保护性因素。对PD患者进行二元Logistic回归分析显示,高龄（OR=1.04,95%CI 1.021～1.059）、低BMI（OR=0.671,95%CI 0.563～0.794）及低血红蛋白（OR=0.962,0.944～0.979）是PEW发生的危险因素。结论 HD患者PEW发生率低于PD患者,使用人体成分分析可辅助诊断PEW的发生,炎症状态是血液透析患者PEW发生的危险因素,提高透析充分性是血透患者PEW的保护因素。高龄、低BMI及低血红蛋白是腹透患者发生PEW的危险因素。

目的研究血液透析患者左心室肥厚（Left ventricular hypertrophy,LVH）的相关因素。方法研究对象为浙江大学医学院附属第一医院慢性肾脏病5期接受血液透析的患者,共175例,采用横断面调查分析方法。采集患者一般情况、血生化检验结果及同时期心脏彩色多普勒超声检测结果,按左室心肌质量指数（Left Ventricular Mass Index,LVMI）分为2组:左室肥厚组（n=90）和左室正常组（n=85）,比较2组生化指标的差异。使用Spearman秩相关和多元线性分析评价左室肥厚的影响因素。结果左室肥厚组年龄、收缩压高于左室正常组,血红蛋白低于正常组,差异有统计学意义（P＜0.05）。Spearman秩相关提示LVMI与年龄、透析前高血压史、糖尿病史、收缩压、空腹血糖呈正相关（r=0.192、0.237、0.173、0.284、0.198,P＜0.05）,与透析龄、尿素清除指数（Kt/V）呈负相关（r=-0.184、-0.233,P＜0.05）。多元线性回归分析提示年龄、透析前高血压史、收缩压、Kt/V与血液透析患者左室肥厚相关（β=0.165、0.205、0.196、-0.184,P＜0.05）。结论高龄、透析前高血压史、高收缩压是透析患者左室肥厚的独立危险因素,Kt/V是左室肥厚的保护因素。控制收缩压、提高透析充分性可能利于减少左室肥厚的发生。

Objective To explore the effect of upgrade of dialysate quality on the microinflammation in maintenance haemodialysis (MHD) patients. Methods Fifty-three MHD patients in Kidney Center of the First Affiliated Hospital,Medical College,Zhejiang University in January 2003 were enrolled in the prospectively study.The main end-points were survival at 8 years or weaning from haemodialysis during 8-year period including death, receiving renal transplantation or transferring to peritoneal dialysis.The endotoxin level of dialysate and patients' serum levels of interleukin-6 (IL-6),tumor necrosis factor α (TNF-α),C reaction protein (CRP),and albumin were recorded during the observation period. Results After the upgrade of water management system,endotoxin level of dialysate obviously decreased [(0.046±0.012) EU/ml vs (0.454±0.002) EU/ml,P＜0.01],and serum IL-6 [(3.947±3.624) ng/L vs (13.779±7.106) ng/L,P=0.036],TNF-α [(7.935±3.864) ng/L vs (12.804±8.017) ng/L,P=0.012] as well as CRP [(0.194±0.149) mg/L vs (0.561 ±0.309) mg/L,P＜0.01] decreased significantly,while serum albumin increased [(41.900±6.803) g/L vs (38.140±7.083) g/L,P=0.042].Hemoglobin level did not change significantly after the system upgrade,however,the dose of erythropoietin decreased [(93.0±12.7) U·kg-1·week-1 vs (131.0±10.1) U·kg-1·week-1,P=0.015]. Conclusions The upgrade of central dialysis fluid delivery and water management system by application of double reverse osmosis,high frequency heat disinfection and endotoxin filter can improve the quality of dialysate.Improvement of dialysate quality can ameliorate the microinflammation state of MHD patients.

目的调查2011年浙江省维持性透析患者的血清钙、磷、甲状旁腺激素水平。方法统计2011年浙江省血液透析和腹膜透析患者血清钙、磷、全段甲状旁腺激素的资料,根据肾脏病改善全球预后（Kidney Disease:Improving Global Outcomes,KDIGO）指南标准,分析患者的钙、磷、iPTH的达标率。结果 2011年浙江省维持性透析患者中,血液透析患者血清钙、磷、iPTH的达标率分别为58.1%、27.2%、56.3%,腹膜透析患者的达标率分别是71.1%、44.2%、65.6%。结论有相当比例的透析患者未能较好的控制血清钙、磷和iPTH水平,尤其是血磷的达标率更低,在血液透析患者中更加明显。

Objective To investigate if rat enhancer of split- and hairy-related protein-2 (SHARP-2) short hairpin RNA interference (shRNAi) prolongs the survival time of rat kidney transplant recipients. Methods Gene recombinant procedures, transfection and co-transfection were carried out to introduce short hairpin RNA interference sequences target for SHARP-2 into 3rd generation self-inactivated lentiviral-ViraPower packaging mix. Limiting dilution method was used for viral titration. Real-time PCR was employed for quantification of gene expression. Rat kidney transplantation was utilized to investigate the effect of SHARP-2 gene silence on the recipient survival. Results A lentiviral-based shRNAi construct LV-SHARP-2iC showed 84% SHARP-2 gene silence efficiency in normal rat kidney cells. At multiplicity of infection 20, 57% T cells could be transfected by lentivirus with spinoculation method. In activated T cells, SHARP-2 g ene silence resulted in 61.3% and 68.7% reduction of intedeukin 2 (IL-2) and interferon γ (IFN-γ) gene expression. When donor kidney was perfused with 5×107 TU LV-SHARP-2iC, the median survival time prolonged for 4-5 days as compared to blank and scramble control groups. Conclusions A recombinant lentivirus LV-SHARP-2iC that effectively silence SHARP-2 gene expression is constructed successfully, leading to the inhibition of IL-2 and IFN-γ. LV-SHARP-2iC treatment can prolong the survival time of rat kidney transplant recipients.

母胎耐受机制的阐明,将为器官移植免疫耐受方案的研究提供重要启示.本研究旨在阐明妊娠状态对父系来源移植皮片的存活是否有保护作用.2月龄雌性C57BL/6小鼠和2～4月龄BALB/c雄性小鼠同笼受孕.采用流式细胞技术确定妊娠过程中调节性T细胞（Treg）比例的时间变化规律.以单向混合淋巴细胞反应（MLR）手段比较研究妊娠对于父系来源脾细胞刺激后产生的增殖反应的影响.通过同种异体小鼠全厚皮片移植模型,观察妊娠对于父系来源移植皮片的存活是否具有保护作用.并用分子生物学技术研究此种效能的可能机制.结果显示,C57BL/6小鼠妊娠过程中,Treg占CD4+T细胞的比例从妊娠前的4.2%逐渐上升,受孕8天左右达到高峰值（6.8%）,此后开始下降并逐渐回复至基线水平.MLR结果表明,针对父系来源脾细胞的刺激,妊娠组较对照组呈现显著的低反应性,其平均刺激指数分别是7.8和13.6（P＜0.05）.定量PCR研究表明,血红素加氧酶-1和吲哚胺2,3双加氧酶mRNA在胎盘高表达,在脾脏低表达（P＜0.05）.父系来源的移植皮片的平均存活时间在妊娠组和非妊娠组分别是7.67和7.08天,无统计学差异（P＞0.05）.由此认为,在小鼠妊娠过程中,尽管出现了具有免疫抑制功能的Treg的比例增加,尽管有针对父系来源刺激细胞的较低的MLR反应性,但是单次妊娠对于父系来源的移植皮片的存活,在本研究条件下,未能显示具有统计学意义的保护作用.

2001年6月～2002年8月,笔者在临床采用中药制剂癃闭舒治疗非细菌性前列腺炎患者25例,与同期使用常规西药治疗的25例对照,获效较后者为优,兹将有关结果介绍如下.